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Management of the severely atherosclerotic aorta during cardiac operations
N T Kouchoukos1, T H Wareing, B B Daily
1Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Insights
This study shows that surgically replacing the ascending aorta during heart surgery significantly reduces stroke risk. This radical approach offers better outcomes for patients with severe atherosclerosis.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Neurosurgery
Background:
- Embolization of atheroma from the ascending aorta is a primary cause of stroke after cardiac surgery.
- Atherosclerosis in the ascending aorta poses a significant risk during cardiovascular procedures.
Purpose of the Study:
- To evaluate a protocol for intraoperative detection and treatment of severely atherosclerotic ascending aorta.
- To assess the efficacy of resection and graft replacement using hypothermic ischemic arrest in preventing stroke.
Main Methods:
- Epiaortic ultrasonographic scanning for intraoperative detection.
- Resection and graft replacement of the ascending aorta.
- Use of hypothermic ischemic arrest during the procedure.
Main Results:
- 47 patients (age ≥50) underwent the procedure during an 81-month interval.
- 30-day mortality rate was 4.3% (2 patients), both due to myocardial failure.
- No strokes or transient ischemic events occurred in surviving patients during follow-up (mean 21 months).
Conclusions:
- Resection and graft replacement of the severely atherosclerotic aorta is associated with lower mortality and stroke rates.
- This technique is a preferred method for managing severe aortic atherosclerosis during cardiac surgery.
- The protocol effectively prevents perioperative and long-term stroke events.
Abstract:
Embolization of atheroma from the ascending aorta is a major cause of stroke following cardiac surgery. We evaluated a protocol for intraoperative detection and treatment of the severely atherosclerotic ascending aorta which included epiaortic ultrasonographic scanning and resection and graft replacement of the involved segment using hypothermic ischemic arrest. During an 81-month interval, 47 patients 50 years of age and older (mean age 71 years) who underwent coronary artery bypass grafting had resection and graft replacement of the ascending aorta. This represented approximately 2% of the patients in this age group who had cardiac operations during this interval. Nineteen patients (40%) required additional procedures. The 30-day mortality rate was 4.3% (2 patients). Both patients died of myocardial failure. None of the 45 surviving patients sustained a perioperative stroke. There have been no strokes or transient ischemic events in the follow-up period, which extends to 72 months (mean 21 months). While this technique for management of the severely atherosclerotic aorta could be considered radical, it was associated with lower mortality and stroke rates than those that were observed in patients with moderate or severe atherosclerosis in whom only minor modifications in technique were made to avoid embolization of atheroma. Resection and graft replacement during a period of hypothermic circulatory arrest is currently our preferred method of treatment for the severely atherosclerotic aorta during cardiac surgery.